Laporan Askep Keperawatan Kritis.docx

KEPERAWATAN KRITIS STIKES BORNEO CENDEKIA MEDIKA PANGKALAN BUN

A. FORMAT PENGKAJIAN KEPERAWATAN KRITIS Tanggal MRS Tanggal Pengkajian Jam Pengkajian Hari rawat ke IDENTITAS 1. Nama Pasien 2. Umur 3. Suku/ Bangsa 4. Agama 5. Pendidikan 6. Pekerjaan 7. Alamat 8. Sumber Biaya

: : : :

Jam Masuk : No. RM Diagnosa Masuk

: :

: : : : : : : :

KELUHAN UTAMA 1. Keluhan Utama : ……………………………………………………….…….……………………………………… ………………………………. ……………………………………………………………………….……………………………… ………………………………………. RIWAYAT PENYAKIT SEKARANG 2. Riwayat PenyakitSekarang: ………………………………………………………………………………....................................... ................................................................. ……………………………………………………………………………………………………… ……....................................................................................................................................................... .................... ……………………………………………………………………………………………………… ……....................................................................................................................................................... .................... ……………………………………………………………………………………………………… ……....................................................................................................................................................... .................... RIWAYAT PENYAKIT DAHULU 1. Pernah dirawat : ya tidak kapan :…… diagnosa :………… 2. Riwayat penyakit kronik dan menular ya tidak jenis…………………… Riwayat kontrol : ............................. Riwayat penggunaan obat :.............. 3. Riwayat alergi: Obat ya tidak jenis…………………… Makanan ya tidak jenis…………………… Lain-lain ya tidak jenis……………………

4. Riwayat operasi: ya - Kapan : …………………… - Jenis operasi : ……………………

tidak

5. Lain-lain: ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... .................................................................................................................................................. ............................................................................................................................................................... ............................................................................................................................................................... RIWAYAT KESEHATAN KELUARGA Ya - Jenis

-

Genogram :

tidak :…………………......................................................................................................... ....................................................................................................................................... ......................................................................................................................................

PERILAKU YANG MEMPENGARUHI KESEHATAN Perilaku sebelum sakit yang mempengaruhi kesehatan: Alkohol ya tidak keterangan……………………...................................................... Merokok ya tidak keterangan……………………...................................................... Obat ya tidak keterangan…..............................................................………….. Olahraga ya tidak keterangan…..........................................................…………….. Masalah Keperawatan :

OBSERVASI DAN PEMERIKSAAN FISIK 1. Tanda tanda vital S: N: T: Kesadaran Compos Mentis Apatis Somnolen

RR : Sopor

2. Sistem Pernafasan (B1) a. RR:................................ b. Keluhan : sesak nyeri waktu nafas Batuk : produktif Sekret:…….. Warna:..........

Koma

orthopnea

tidak produktif Konsistensi :...................... Bau :..................................

c. Penggunaan otot bantu nafas: ....................................................................................................................................................... ....................................................................................................................................................... . d. Irama nafas teratur tidak teratur e. Pola nafas Dispnoe

Kusmaul

f. Suara nafas Cracles

Ronki

Cheyne Stokes

Biot

Wheezing

g. Alat bantu napas ya tidak Jenis................................................ Ventitalor Mode : FiO2 : PEEP : SaO2 :

Flow..............lpm

Vol. Tidal I:E Ratio Lain-lain

: : :

h. Penggunaan WSD: - Jenis - Jumlah cairan - Tekanan

: ................................................................................................ : ................................................................................................ : ................................................................................................

i. Tracheostomy: ya tidak ....................................................................................................................................................... ....................................................................................................................................................... . j. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... ..........................................................................................................

3. Sistem Kardio vaskuler (B2) a. Keluhan nyeri dada: ya P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :...................................................................

tidak

Masalah Keperawatan :

b. Irama jantung: reguler

ireguler

c. Suara jantung: normal (S1/S2 tunggal) murmur gallop lain-lain..... d. Ictus Cordis: ....................................................................................................................................................... .................................................................................

e. CRT :.............detik f. Akral: hangat kering pucat g. h. i. j.

panas

merah

dingin

Sikulasi perifer: normal menurun JVP :................................. CVP :................................. CTR :.................................

basah

k. ECG & Interpretasinya: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....... l. Lain-lain : ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....

4. Sistem Persyarafan (B3) a. GCS : .................................................. b. Refleks fisiologis patella

triceps

biceps

c. Refleks patologis babinsky

brudzinsky

kernig

Lain-lain:................................................................. Masalah Keperawatan :

d. Keluhan pusing ya tidak P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :................................................................... e. Pemeriksaan saraf kranial: N1 : normal tidak Ket : …….............................................................. N2 : normal tidak Ket : …….............................................................. N3 : normal tidak Ket : …….............................................................. N4 : normal tidak Ket : …….............................................................. N5 : normal tidak Ket : …….............................................................. N6 : normal tidak Ket : ……..............................................................

N7 : normal tidak Ket : …….............................................................. N8 : normal tidak Ket : …….............................................................. N9 : normal tidak Ket : …….............................................................. N10 : normal tidak Ket : …….............................................................. N11 : normal tidak Ket : …….............................................................. N12 : normal tidak Ket : …….............................................................. f. Hoffman/Tromer test : g. Pupil anisokor isokor Diameter: ……/...... h. Sclera anikterus ikterus i. Konjunctiva ananemis anemis j. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ........................ k. IVD :................................................ l. EVD :................................................ m. ICP :................................................ n. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ...... o. Tanda-Tanda PTIK: p. Gangguan pendengaran: q. Gangguan penglihatan : r. Gangguan Penciuman ;

Ada Ada Ada

Tidak , Jelaskan: Tidak, Jelaskan: Tidak, Jelaskan ;

5. Sistem perkemihan (B4) a. Kebersihangenetalia: Bersih Kotor b. Sekret: Ada Tidak c. Ulkus: Ada Tidak d. Kebersihan meatus uretra: Bersih Kotor e. Keluhan kencing : Ada Tidak Bila ada, jelaskan: ....................................................................................................................................................... ....................................................................................................................................................... .... Masalah Keperawatan

f. Kemampuan berkemih: Sponta Alat bantu, sebutkan: ............................... Jenis:............................................ Ukuran :............................................ Hari ke :............................................ g. Produksi urine : ………….. ml/jam Warna :............…… Bau :......………..

h. Kandung kemih Membesar : ya tidak i. Nyeri tekan : ya tidak j. Intake cairan : oral : ….. cc/hari parenteral : …… cc/hari k. Balance cairan: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ... a. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ... 6. Sistem pencernaan (B5) a. TB :............... BB :............................ b. IMT :............... Interpretasi :............................ c. LOLA :............... Masalah Keperawatan :

d. Mulut: bersih kotor berbau e. Membran mukosa: lembab kering stomatitis f. Tenggorokan: sakit menelan kesulitan menelan pembesaran tonsil nyeri tekan g. Abdomen: tegang kembung ascites h. Nyeri tekan: ya tidak i. Luka operasi: ada tidak Tanggal operasi :................ Jenis operasi :................ Lokasi :................ Keadaan :................ Drain : ada tidak - Jumlah :................... - Warna :................... - Kondisi area sekitar insersi :................... j. Peristaltik:.............. x/menit k. BAB: ......................x/hari Terakhir tanggal : ............... l. Konsistensi: keras lunak cair lendir/darah m. Diet : padat lunak cair n. Diet Khusus: ....................................................................................................................................................... ..................................................................................................... o. Nafsu makan: baik menurun Frekuensi:.......x/hari p. Porsi makan: habis tidak Keterangan:................... q. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... ....

7. Sistem muskuloskeletal (B6) a. Pergerakan sendi: bebas b. Kekuatan otot:

terbatas

c. Kelainan ekstremitas: ya tidak d. Kelainan tulang belakang: ya tidak Masalah Keperawatan :

e. Fraktur: ya tidak - Jenis :................... f. Traksi: ya tidak - Jenis :................... - Beban :................... - Lama pemasangan :................... g. Penggunaan spalk/gips: ya tidak h. Keluhan nyeri: ya tidak P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :................................................................... i. Sirkulasi perifer: .............................................. j. Kompartemen syndrome: ya tidak k. Kulit: ikterik sianosis kemerah hiperpigmentasi l. Turgor: baik kurang jelek m. Luka operasi: ada tidak Tanggal operasi :................ Jenis operasi :................ Lokasi :................ Keadaan :................ Drain : ada tidak - Jumlah :................... - Warna :................... - Kondisi area sekitar insersi :................... n. ROM : ................................................ o. Lain-lain: ....................................................................................................................................................... ..................................................... p. Pitting edema: +/- grade:................ Masalah Keperawatan : q. Ekskoriasi: s: ya tidak r. Urtikaria: ya tidak s. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... .... 8. Sistem Endokrin a. Pembesaran tyroid: b. Pembesaran kelenjar getah bening: c. Hipoglikemia: d. Hiperglikemia:

ya ya ya ya

tidak tidak tidak tidak

e. Lain-lain:..................Jelaskan:.................................................. Masalah Keperawatan :

PENGKAJIAN PSIKOSOSIAL f. Persepsi klien terhadap penyakitnya: .............................................................................................................................................................. .............................................................................................................................................................. ................. g. Ekspresi klien terhadap penyakitnya Murung/dia gelisah tegang marah/menangis h. Reaksi saat interaksi kooperatif tidak kooperatif curiga i. Gangguan konsep diri: .............................................................................................................................................................. ................................................................ ............................................................................................................... j. Lain-lain: .............................................................................................................................................................. ..................... Masalah keperawatan :

PERSONAL HYGIENE & KEBIASAAN Jelaskan :.........................................................Masalah Keperawatan : .......................................................... ..........................................................

PENGKAJIAN SPIRITUAL a. Kebiasaan beribadah - Sebelum sakit: sering kadang- kadan - Selama sakit : sering kadang- kadang

tidak pernah tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah: .............................................................................................................................................................. ............................................................... Masalah Keperawatan :

PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll) .................................................................................................................................................................... .................................................................................................................................................................... ...................................................................................................................................................................

TERAPI .................................................................................................................................................................... .................................................................................................................................................................... ..................................................................................................................................................................

DATA TAMBAHAN LAIN : .................................................................................................................................................................... .................................................................................................................................................................... ....................................................................................................................................................................

ANALISIS DATA TANGGAL

DATA

ETIOLOGI

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN TANGGAL: ................................. 1. 2. 3. 4. 5. 6.

MASALAH

RENCANA INTERVENSI HARI/ TANGGAL

WAKTU

DIAGNOSA KEPERAWATAN (Tujuan, Kriteria Hasil)

INTERVENSI

IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tgl Shift

No. DK

Jam

Implementasi

Jam

Evaluasi (SOAP)

Paraf